Provider First Line Business Practice Location Address:
1322 S PRAIRIE AVE
Provider Second Line Business Practice Location Address:
UNIT 1102
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60605-3064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-576-5264
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2007